Blog | Tuesday, May 21, 2013

QD: News Every Day--Wording change affects surrogates' end-of-life choices for loved ones

Small wording changes made big differences in end-of-life decisions for surrogates of critically ill patients, a study found.

Researchers conducted a web-based simulated meeting to discuss code status using 256 volunteers randomly assigned to consider a hypothetical scenario in which their spouse or parent was receiving life-sustaining treatment in an intensive care unit. An actor portrayed an intensivist, who at the end of the interview discloses a 10% likelihood of survival in the event of cardiac arrest requiring cardiopulmonary resuscitation (CPR). The actor then asked surrogates to decide the patient's code status.

Results of the study, co-authored by Robert M. Arnold, MD, FACP, appeared online at Critical Care Medicine.

While emotional triggers didn't influence the outcomes, researchers noted that three framing manipulations that mattered included implying the social norm was not to choose CPR, phrasing that the decision was the patient's vs. the surrogate's, and describing the alternative to CPR as "allow natural death" vs. "do not resuscitate [DNR]."

Emotional triggers--seeing pictures and scenarios with the loved one as opposed to seeing neutral scenes before making the choice about CPR--did not impact CPR choice. But framing the social norm as not choosing, rather than choosing, CPR resulted in fewer decisions to resuscitate (48% vs 64%; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.32 to 0.87), as did framing the alternative to CPR as "allow natural death" rather than DNR (49% vs 61%; OR, 0.58; 95% CI, 0.35 to 0.96).

Researchers wrote, "[W]e provide the first empiric evidence that this phrase, which has been integrated into the language of several health systems, may directly influence code status decisions."

Angelo Volandes, MD, ACP Member, tells The Atlantic that unwanted end-of-life treatments are "wrongful care." He describes a project that will teach patients and surrogates How Not to Die.

An experience he had as a medical resident showed him that patients needed to see examples of end-of-life care--what a CPR attempt is really like--for them to understand what's involved in that decision. He and Aretha Delight Davis, MD, ACP Associate Member, are now creating videos to show surrogates who may face such decisions.

Dr. Volandes told The Atlantic, "Videos communicate better than just a stand-alone conversation. And when people get good communication and understand what's involved, many, if not most, tend not to want a lot of the aggressive stuff that they're getting."